ABSTRACT

Context Criteria for potentially inappropriate medication use among elderly
patients have been used in the past decade in large US epidemiological surveys
to identify populations at risk and specifically target risk-management strategies.
In contrast, in Europe little information is available about potentially inappropriate
medication use and is based on small studies with uncertain generalizability.

Objective To estimate the prevalence and associated factors of potentially inappropriate
medication use among elderly home care patients in European countries.

Design, Setting, and Participants Retrospective cross-sectional study of 2707 elderly patients receiving
home care (mean [SD] age, 82.2 [ 7.2] years) representatively enrolled
in metropolitan areas of the Czech Republic, Denmark, Finland, Iceland, Italy,
the Netherlands, Norway, and the United Kingdom. Patients were prospectively
assessed between September 2001 and January 2002 using the Minimum Data Set
in Home Care instrument.

Main Outcome Measures Prevalence of potentially inappropriate medication use was documented
using all expert panels criteria for community-living elderly persons (Beers
and McLeod). Patient-related characteristics independently associated with
inappropriate medication use were identified with a multiple logistic regression
model.

Results Combining all 3 sets of criteria, we found that 19.8% of patients in
the total sample used at least 1 inappropriate medication; using older 1997
criteria it was 9.8% to 10.9%. Substantial differences were documented between
Eastern Europe (41.1% in the Czech Republic) and Western Europe (mean 15.8%,
ranging from 5.8% in Denmark to 26.5% in Italy). Potentially inappropriate
medication use was associated with patient’s poor economic situation
(adjusted relative risk [RR], 1.96; 95% confidence interval [CI], 1.58-2.36),
polypharmacy (RR, 1.91; 95% CI, 1.62- 2.22), anxiolytic drug use (RR, 1.82;
95% CI, 1.51-2.15), and depression (RR, 1.29; 95% CI, 1.06-1.55). Negatively
associated factors were age 85 years and older (RR, 0.78; 95% CI, 0.65-0.92)
and living alone (RR, 0.76; 95% CI, 0.64-0.89). The odds of potentially inappropriate
medication use significantly increased with the number of associated factors
(P<.001).

Conclusions Substantial differences in potentially inappropriate medication use
exist between European countries and might be a consequence of different regulatory
measures, clinical practices, or inequalities in socioeconomic background.
Since financial resources and selected patient-related characteristics are
associated with such prescribing, specific educational strategies and regulations
should reflect these factors to improve prescribing quality in elderly individuals
in Europe.

Figures in this Article

Use of potentially inappropriate medications in elderly patients is
a major health care concern. It is likely to increase the risk of adverse
drug events, which are estimated to be the fifth most common cause of death
among hospitalized patients1 and which account
for a large number of hospital admissions and a substantial increase in health
care costs.2

In the United States and Canada, epidemiological studies have documented
widespread use of potentially inappropriate medications among nursing home
residents (up to 40%) and community-dwelling elderly persons (14%-37%).3- 13 In
general, these studies have adopted explicit criteria developed by panels
of experts, which recommend avoiding medications with a high potential for
adverse events and prefer alternatives with lower risk. Most medications are
deemed inappropriate independently of clinical indications and concomitant
diagnoses, dosing, or concurrent medications.14- 17

In the United States, explicit criteria were initially developed for
nursing home residents (Beers et al 1991),14 and
later for community-dwelling elderly individuals (Beers 1997).15 Although
another set of criteria was created for Canada (McLeod et al 1997),16 Beers 1997 criteria in their original or revised
version (Zhan et al 2001)4 have been used most
commonly in epidemiological research. These criteria were recently updated
(Beers 2003)17 to reflect newly attained evidence
on efficacy and safety of various medications.

In Europe, no similar criteria have been developed, owing to substantial
differences in national drug formularies and prescribing attitudes, as well
as the criticism that explicit criteria cannot fully capture all factors defining
drug appropriateness. As a result, few studies describing potentially inappropriate
medication use have been conducted, mainly in the Nordic countries (Sweden,
Finland)18,19 and in Italy.20 These studies usually adopted Beers 1997 criteria
and documented a somewhat lower prevalence of inappropriate medication use
than in the United States, ranging from 12.1% (Finland) to 14.6% (Italy).
Performed in specific populations, diverse settings, and at a different time,
these studies have little comparability. Until European-specific criteria
for potentially inappropriate medication use that consider country-specific
formularies are created, the Beers and McLeod criteria represent available
standards of currently identified inappropriate medications in elderly patients
and the best method for cross-sectional assessment of potentially inappropriate
medication use in Europe.

Thus, the aims of our study were to determine in a large sample of European
home care elderly patients the prevalence of potentially inappropriate medication
use, applying all available sets of criteria, and to identify independent
correlates of potentially inappropriate medication use.

METHODS

This is an ancillary study of the AdHOC (Aged in Home Care) project,
a multicenter project funded by the European Union Commission under the Vth
Framework Programme (2000-2003). The AdHOC project was designed to compare
the case-mix of elderly patients receiving home care services across 11 European
countries along with a series of structural and organizational characteristics
of the services themselves. The project has been approved by the ethics committees
of participating countries and written consent was obtained from all participants.
The AdHOC project has been described in detail elsewhere21 and
its principal features are briefly outlined herein.

Based on power calculations (NCSS Pass 6.0 statistical software; NCSS
Statistical Software, Kaysville, Utah), a sample size of 350 patients for
each area allowed 80% power to detect significant variations in indices of
functional ability (the outcome variables for the main study) within each
catchment area with a probability error of .05. We assumed a corresponding
dropout rate of 15% or less and thus 405 patients were randomly selected in
each country. Among the 8 countries participating in our study, 4 (Denmark,
Iceland, Italy, and Norway) achieved planned participation rates and were
representative of the national home care elderly populations. Three countries
(Finland, United Kingdom, the Netherlands) exceeded estimated refusal rates
mostly due to patients’ unwillingness to be troubled or fear of what
was involved. The Czech Republic was only marginally above the 15% refusal
rate.21 All samples significantly differed
from the national statistics on the elderly population by age, sex, and the
prevalence of major comorbidities (P<.001). Considering
that inappropriate medication use should be independent of the population
structure and comorbidities, all samples finally entered the statistical analysis.

Comprehensive Geriatric Assessment

All patients were assessed at home by specifically trained staff, either
home care nurses or research assistants. Detailed information was recorded
using the inter-RAI Minimum Data Set for Home Care instrument (MDS-HC),22,23 which was translated, back-translated,
and examined for face validity in the language of each participating country.
Assessments were completed at baseline and after a 1-year study period, with
a 6-month briefer reassessment using only selected items. For our cross-sectional
analysis, baseline data were used.

The MDS-HC instrument consists of more than 350 items, including sociodemographic,
physical, cognitive, and psychological characteristics of the patient, as
well as relevant clinical information. The MDS-HC has excellent interrater
reliability and has been used for epidemiological research in both the United
States and Europe.21- 23 Information
about psychosocial and medical conditions and medication use was recorded
based on interviews with patients and caregivers as well as medical record
review. Information on current and past services utilization was also gathered,
including hospitalization in the prior 30 days, nursing home stay in the prior
5 years, and emergency home or emergency department visits 3 months prior
to the assessment.

Drug Information

In addition to MDS-HC data, assessors collected information on all the
medications patients had been taking in the prior 7 days—both prescribed
and over-the-counter medications—used regularly or on an as-needed basis.
Drug information included nonproprietary and proprietary name, Anatomical
Therapeutic and Chemical code, formulation, dosage, frequency, and route of
administration.

Investigators documented whether patients or caregivers reported that
any physician had provided a medication review in the previous 6 months and
whether patients were adherent with the prescription within a week preceding
the assessment. Assessors also reviewed physicians’ medical records
or patients’ discharge sheets, if available, to assess medication use
and adherence. To further assess adherence, patients’ pillboxes were
also checked if available.

Nonadherence was coded when the patient was less than 80% adherent to
all medications used in the prior 7 days. Patients were also asked if they
had experienced economic difficulties in the prior 30 days that precluded
them from being able to pay for prescribed medications, heating, medical care,
adequate nutrition, and home help or home care. Patients reporting any difficulties
were classified as having poor economic status.

Criteria for Potentially Inappropriate Medication Use

To determine the use of potentially inappropriate medications, we adopted
all explicit criteria previously published by panels of experts for community-living
elderly individuals (Table 1), using
them separately and all combined. We adopted only parts of criteria related
to “medications that should be avoided in the elderly” excluding
sections related to drug-drug and drug-disease interactions. Thus, our study
describes only errors of commission (medications that generally should not
be prescribed) but not other types of prescribing errors (eg, errors of omission).
Although the Beers 2003 criteria had not been published at the time the data
were collected, information regarding adverse events associated with these
drugs in elderly patients was available at that time and these criteria were
included to improve comparability with other studies.

When several definitions of inappropriateness for a substance were present
on the combined criteria list, the latest published definition was accepted
to determine the whole prevalence (eg, short-acting oxybutynin [Beers 2003
criteria] instead of all formulations of oxybutynin [Beers 1997 criteria]).
Expert panel criteria were used as a screening tool with regard to specific
comorbidities that might affect prescribing appropriateness. We considered
all potentially inappropriate medications (with the exception of stimulant
laxatives) where definition of inappropriateness was limited to long-term
use that we could not ascertain. For the same reason, the definition of inappropriateness
for nonsteroidal anti-inflammatory drugs was limited to the use of a maximum
daily dose irrespective of the length of the exposure. Only systemically acting
drug formulations were analyzed.

Analytical Approach

Descriptive MDS-HC data from the baseline assessment, including sociodemographic
characteristics (eg, age, sex, living alone, lack of informal helper, economic
status) as well as functional, cognitive, and mood status characteristics,
were computed for each country and for the total sample. Activities of daily
living (ADLs) disability was defined as a score of at least 2 on the MDS-HC
ADL Scale that was computed using items on patients’ performance in
personal hygiene, toilet use, locomotion, and eating.24 Instrumental
activities of daily living (IADLs) disability was classified as dependency
in at least 2 of the following: meal preparation, ordinary housework, managing
finances, managing medications, telephone use, shopping, and transportation.22 Cognitive impairment was determined as a score of
at least 2 on the Cognitive Performance Scale (CPS),25 a
validated instrument (range, 0-6; a score of 2 corresponds to 22 on the Mini-Mental
State Examination). Clinically significant depression was defined as a score
of at least 3 on the Depression Rating Scale (DRS; range, 0 [intact] through
14 [severely depressed]).26

Statistical Analysis

Data were analyzed using SPSS software version 12 (SPSS Inc, Chicago,
Ill) and Egret software version 2.03 (Cytel Software Corporation, Cambridge,
Mass). Differences in distributions of categorical variables among countries
and between users and nonusers of inappropriate medications were compared
using the χ2 test.

A multiple logistic regression model was created to determine patient-related
characteristics associated with inappropriate medication use. Only dichotomous
variables were entered into the logistic regression model. Multicollinearity
was tested using the χ2 test and the coefficient of contingence,
which determines the strength of the association between 2 dichotomous variables
(value range from 0 to 1, where 0 equals complete independence).

A stepwise logistic regression was applied in the exploratory phase
of the statistical modeling. Due to the great number of potential predictive
variables and interactions among them, variables were tested gradually simultaneously.
The Wald test and the likelihood ratio test were used to test the significance
of a single predictive variable. The variable was included in the model only
if both tests were statistically significant. To test the overall significance
of the model, the model χ2 statistic was applied. We also
computed the goodness-of-fit χ2 statistic (–2 ×
the log likelihood) to measure the model fitness and Nagelkerke R2 statistic to determine the strength of associations between
inappropriate medication use and predictive variables. The degree of excess
heterogeneity due to overdispersion was explored.

Because inappropriate medication use was common in the whole sample
(>10%), the adjusted odds ratios could not be used to approximate the relative
risks (RRs). The method of Zhang and Yu was applied to estimate the RRs.27 The trend of the unadjusted odds for the use of an
inappropriate medication with increasing number of associated factors was
tested using the Mantel-Haenszel statistic. A 2-tailed P<.05 was selected as the level of statistical significance.

RESULTS

Principal characteristics of the population studied are shown in Table 2. Mean (SD) age of the patients was 82.2
(7.2) years; most were women (74.4%) and lived alone (61.2%), but rarely reported
a poor economic situation (7.6%). Most of the patients were dependent in IADLs
(69.8%), but fewer were dependent in ADLs (39.3%). A minority had cognitive
impairment (28.6%) or clinical depression (16.6%). Differences among countries
were statistically significant for all variables presented in Table 2.

When 7-day prevalence of medication use was evaluated, more than 95%
of patients received at least 1 medication and polypharmacy (defined as the
use of ≥6 medications) was documented in 51.0% of patients. Medication
adherence was high except in the Czech Republic; reported lack of regular
medication review ranged from 3.9% in Italy to 56.4% in the United Kingdom.

Considering all explicit criteria combined, 19.8% used at least 1 potentially
inappropriate medication. The highest prevalence (41.1%) was documented in
the Czech Republic compared with a mean of 15.8% for all the other countries,
ranging from 5.8% in Denmark to 26.5% in Italy (Figure 1). Results using only Beers 2003 criteria were similar to
those obtained with combined criteria except in the Czech Republic. The application
of Beers 1997 or McLeod criteria yielded half the prevalence of the total
sample and 1.2- to 3.9-fold lower prevalence in individual countries (Figure 2).

Table 3 presents the 10 most commonly
used inappropriate medications considering all explicit criteria combined.
While some medications, namely diazepam and amitriptyline, were frequently
used in all countries, others were prescribed to a higher extent only in certain
countries, eg, pentoxifylline, high-dose digoxin, and chlordiazepoxide in
the Czech Republic; ticlopidine and amiodarone in Italy; and unopposed estrogens
in older women in Iceland.

Based on several types of patient characteristics (Table 4), 6 variables were identified as independent predictors
of inappropriate medication use (Table 5).
Individuals reporting a poor economic situation had a 1.96-fold higher relative
risk of receiving an inappropriate medication than the reference group. This
factor was significantly associated with living in the Czech Republic (contingency
coefficient, 0.38; P<.001), where 32.7% of patients
reported a poor economic situation compared with an average of 2.9% in all
the other countries. The relative risk of inappropriate medication use was
1.8-fold higher among users of anxiolytic drugs and 1.9-fold higher among
patients receiving 6 or more medications. Polypharmacy covaried with having
4 or more medical conditions (contingency coefficient, 0.36; P<.001). Depression appeared to be a weaker predictive variable
(RR, 1.29; 95% CI, 1.06-1.55). On the other hand, individuals aged 85 years
or older and those living alone were less likely to receive inappropriate
medications. We found a significant colinearity between not living alone and
dependency in self-care (contingency coefficient, 0.31; P<.001). Relative risks derived from the corresponding odds ratios
were all statistically significant (Table 5).
All associated factors were significant in individual countries except poor
economic situation, which was a country-specific factor (Czech Republic).
Collinearity between associated factors and other variables than tested was
excluded.

Although the logistic regression model was statistically significant
(P<.001), a large amount of variability remained
unexplained (Nagelkerke R2 coefficient,
11.0%). However, the likelihood of being prescribed an inappropriate medication
increased exponentially (P<.001) with the number
of predictive variables and reached an odds ratio of 10.96 in patients with
at least 4 predictive factors (Figure 3).

Figure 3. Odds of Potentially Inappropriate
Medication Use According to the Number of Patient-Related Predictive Factors

COMMENT

While US national surveys have documented that among community-dwelling
elderly persons more than 7 million use potentially inappropriate medications,4 no such evidence has been available for Europe. In
fact, small-scale national studies have been conducted only in a few European
countries using different methods and with little comparability.18- 20 To
our knowledge, the findings of this study represent the first comparative
estimates of potentially inappropriate medication use in a large sample of
community-dwelling elderly persons in major metropolitan areas of 8 European
countries. In addition, this study compared all available explicit criteria
of inappropriate medication use to generate the most comprehensive evaluation
of this issue in Europe, where specific criteria are not available.

Differences Between Europe and North America

Differences exist between panels of medications available in the United
States and in countries in Europe, as well as across countries in Europe.
Several potentially inappropriate medications listed in the criteria were
not approved in all AdHOC countries (eg, chlorzoxazone, halazepam, quanadrel,
metaxalon, methocarbamol, nylidrin, oxaprozin, phenylbutazone, quazepam, trimethobenzamide).
While in some national formularies selected inappropriate medications are
not available, eg, belladonna alkaloids (Italy), hyosciamine (Iceland), and
pentoxifylline (Norway), other countries use these drugs rarely in elderly
patients (hyosciamine in Finland and Italy, pentoxifylline in Finland) or
frequently (eg, long-acting benzodiazepines and pentoxifylline in Czech Republic).
Overall, nearly half the medications from the combined list were not approved
in most of the European countries.28- 35 The
percentage of approved drugs in individual countries was 31.6% in Norway,
48.1% in the Netherlands, 50.6% in Iceland, 51.9% in Denmark, and Czech Republic,
55.7% in Finland and United Kingdom, and 70.9% in Italy.

Moreover, some medications not available in the United States (eg, flunitrazepam
and etofylline) are available in Europe and have potentially harmful properties
similar to medications on the list. These specific substances should be identified
in the future by expert panel groups in Europe. It is also likely that economic
constraints contribute substantially to inappropriate medication use. For
example, ticlopidine was recommended for use in elderly patients consistently
in all countries except in Norway. Clopidrogel, believed to be a safer alternative,15,17 was more expensive and therefore
economically unavailable.

As discussed previously, no criteria for potentially inappropriate medications
have been developed for European countries. Until such criteria are available,
existing standards permit comparisons of inappropriate medication use across
countries and our study provides the most comprehensive cross-sectional estimate
of this issue in Europe to date. Considering all explicit criteria combined,
we found a 20% prevalence of inappropriate medication use. This estimate is
similar to those documented by epidemiological surveys in the United States.
These surveys found that applying only Beers 1997 criteria, a prevalence of
inappropriate medication use yielded 21% in community-dwelling elderly individuals4 and 23% in Medicare-managed care elderly patients.13 When we considered the same approach (Beers 1997
criteria), the prevalence of inappropriate medication use appeared to be lower
(<11% in the majority), in agreement with results of previous small-scale
studies from Finland, Sweden, and Italy.18- 20 However,
longer assessment periods tend to find higher prevalence rates, suggesting
that an assessment longer than our 7 days might find different results. It
is also likely that the absence of many inappropriate medications in the European
national formularies accounted in part for the “relatively better prescribing
practice” in Europe.

Differences Among European Countries

The prevalence of inappropriate medication use varied substantially
among countries. The most striking was the difference between the Czech Republic
and countries in Western Europe. In Prague, 41% of home care elderly patients
were prescribed at least 1 inappropriate medication compared with only 16%
in Western European countries. It is likely that prescribing habits along
with socioeconomic factors, including prescribing limits and patients’
inability or unwillingness to co-pay for safer alternatives, were responsible
for the high proportion of potentially inappropriate medication use in the
Czech Republic. Indeed, other studies have documented reduced access to safer
treatments36 and higher frequency of potentially
inappropriate prescriptions in low-income elderly.37 Noticeably,
the findings for the Czech Republic were greatly influenced by the very frequent
use of pentoxifylline (>20%), which is considered potentially inappropriate
based solely on the McLeod 1997 criteria. While a detailed evaluation of this
finding is beyond the scope of this study, our results confirm recent data
that pentoxifylline belongs to the top 10 most commonly prescribed medications
in the Czech Republic.38

Substantial differences were also found among Western European countries,
with a higher prevalence of potentially inappropriate medication use in Italy
and Finland. However, it should be noted that nearly 50% of this prevalence
represented potentially inappropriate medications that particularly in low-dose
regimens “might have some indications in the old age” based on
recommendations of national drug formularies (eg, diazepam and amitriptyline
in Finland, amiodarone and ticlopidine in Italy).28- 35 We
could not evaluate appropriateness at the individual patient level and as
such our findings should be corroborated by further studies.

These limitations notwithstanding, the extensive use of some inappropriate
medications in particular countries is concerning and merits further study.
In agreement with our findings, a recent study in Italy confirmed ticlopidine
and amiodarone to be the most commonly prescribed potentially inappropriate
medications.39 In Finland, a national study
has documented that psychotropic drugs are often inappropriately prescribed
in community-dwelling elderly patients, particularly diazepam for the treatment
of depression.40

The differences in inappropriate medication use might also be influenced
by country-specific regulatory measures. The strikingly low prevalence in
Denmark despite high rates of polypharmacy is likely related to drug utilization
review provided by the National Institute of Health with feedback to individual
physicians.41 Similarly, in the United Kingdom,
implementation of guidelines and clinical pharmacists’ auditing has
probably contributed to lower prevalence of inappropriate medication use.42 In the United States, computerized alert systems
with personal feedback to physicians effectively reduced the amount of newly
prescribed inappropriate medications.43

Our findings document that the addition of several substances into the
Beers 2003 list nearly doubled the prevalence obtained with Beers 1997 criteria.
This might indicate physicians’ better knowledge of older Beers criteria
and less confidence with newly attained pharmacoepidemiological and pharmacological
evidence confirming harmful properties of several other medications later
included in the Beers 2003 list (eg, short-acting nifedipine, short-acting
oxybutynin, daily fluoxetine) (Table 1).42,44

Factors Associated With Inappropriate Medication Use

In agreement with previous US studies, similar independent predictors
of inappropriate medication use were identified in Europe: patient’s
poor economic situation, polypharmacy, anxiolytic drug use, and depression.1,10,18 On the other hand,
individuals aged 85 years or older or living alone were significantly less
likely to receive inappropriate medications.4,9,10

Many studies have highlighted polypharmacy as a significant risk for
inappropriate medication use, adverse drug events, for the increase in health
care utilization, and costs.45 In addition,
patients with depression and elderly patients treated with psychotropic medications
are at risk for inappropriate prescription.10,18,43 Studies
from the United States and Canada have confirmed that auditing drug regimens
in these populations might reduce the prevalence of inappropriate medication
use.1,6,9

Individuals living alone might be less likely to receive a potentially
inappropriate medication as a consequence of less frequent contact with primary
care physicians.4 Similar reduced risk in patients
85 years or older could be explained by greater physician awareness of this
issue in the oldest old9 or by a higher mortality
rate in this age group.

No other characteristics (eg, recent medication review, cognitive impairment,
hospitalization in the past 30 days) were associated with inappropriate medication
use. Despite a number of patient-related characteristics being tested, a large
amount of variance in the model remained unexplained. It is likely that physician-related
factors might account for a significant part of this variance (eg, knowledge
of the expert panels’ criteria, adherence to guidelines, amenability
to pharmaceutical marketing). Due to strong societal or individual influences
on prescribing practice,1,17 these
factors should be considered in future sociobehavioral studies.

Limitations

Our results need to be interpreted with caution due to several limitations.
Results of our study cannot be generalized to the whole community-dwelling
elderly population because of the higher frailty of home care elderly patients.
Additionally, because inappropriate medication use is sensitive to regional
marketing strategies and prescribing practices, our findings are not generalizable
to other European countries. We were unable to determine country-specific
factors associated with inappropriate medication use due to small samples;
future large studies should explore this issue. Also, residual confounding
is always a possibility.

An important concern is the very definition of “inappropriateness,”
which is rather relative than absolute. Under specific circumstances, some
“inappropriate” medications might be appropriately indicated.
However, the design of our study did not allow evaluating the medication appropriateness
at an individual level and our results only screen populations at risk. We
cannot dismiss conclusively the possibility that some individuals had tried
safer alternatives in the past. Finally, we cannot imply that inappropriate
medication use is necessarily linked to negative outcomes because this analysis
was cross-sectional. However, current reports confirm these associations.13,46

CONCLUSIONS

In Europe, use of potentially inappropriate medications among frail
community-dwelling elderly persons appears to be common, with substantial
regional variations. The differences likely reflect country-specific drug
policies, care provision differences, inequalities in socioeconomic background,
differences in overall health conditions, and specific regulatory measures.
While regional preferences for some inappropriate medications need a more
in-depth evaluation, these variations indicate amenability to intervention,
particularly in Eastern Europe. Future efforts should be targeted to modifiable
correlates of inappropriate medication use and research should focus on outcomes
and intervention strategies.

Despite previous criticism of the expert panels’ criteria for
their simplicity,17 these tools increase clinicians’
awareness about potentially inappropriate medications for older patients.
Thoughtful adoption of these criteria by regulatory institutions, national
guidelines, and computerized alert systems might improve prescribing. Because
one of the current principal aims of the European Union is to improve practice,
rules, and regulations throughout Europe, harmonizing drug policy and regulatory
measures with respect to potentially inappropriate medication use should be
a major focus (eg, withdraw ineffective and/or harmful medications, establish
prescribing limits for the elderly, approve safer alternatives, harmonize
prescribing guidelines). These strategies could help ensure that prescribing
for older patients in Europe is improved and consistent across countries.

Funding/Support: Our study is an ancillary
study of the European AdHOC (Aged in Home Care) project, supported by the
EU Commission under the Vth Framework Programme (contract QLRT 2000-00002).

Role of the Sponsors: The EU Commission had
no role in the design and conduct of the study; collection, management, analysis,
and interpretation of the data; or in the preparation, review, or approval
of the manuscript.

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